197494814-6-25-2021-30-CC-MSIN-C4BPR3-20210625113205

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197494814
Report Date: 06/25/2021
Date Signed: 06/25/2021 11:33:47 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245

FACILITY NAME:	BENABU FAMILY CHILD CAEW		FACILITY NUMBER:	197494814
ADMINISTRATOR:	BENABU, SHIRANI		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(818) 671-9903
CITY:	TARZANA	STATE: CA	ZIP CODE:	91335
CAPACITY:	14	CENSUS: 0	DATE:	06/25/2021
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	10:10 AM
MET WITH:	Shirani Benabu		TIME COMPLETED:	11:00 AM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Tele-Visit via Face-time. Licensee has been advised that an email shall be sent with the report attached, which has been reviewed during the Tele-Visit and a read receipt via email shall be considered an acknowledgement that they are in receipt of this form. This is an announced pre-licensing tele-visit conducted by Margarit Sislyan, Licensing Program Analysts (LPA) on 6/25/21 at 10:10 AM with Applicant, Shirani Benabu who guided analyst on a tele-tour at the facility. This is one story single room ADU detached from the main house ( 6306 Melvin Ave., Tarzana CA 91335). The access to the facility is from the side yard. Two windows of the main house are looking to the side yard. The outdoor area was separated from the main house with a mesh fence. There is a pool on the premises of the main house. The kitchen window of the ADU was opening to the pool area of the main house. Family members residing at facility are: 1 adults and no children. The home was inspected for safety, comfort, cleanliness, heating and ventilation, inaccessibility to poisons, detergents, cleaning compounds, medicines, and hazardous items that can pose a danger to children. Per applicant there are no weapons or firearms of any kind in the facility currently. There are age appropriate toys and equipment on the premises. Applicant has provided proof of Preventative Health and Safety. CPR expires on 4/7/2023. The required fire extinguisher (2A10BC), combined smoke detector and carbon monoxide detector is in operable condition. Page 1 of 3

SUPERVISOR'S NAME: Mary Ruiz	TELEPHONE: (424) 301-3061
LICENSING EVALUATOR NAME: Margarit Sislyan	TELEPHONE: (424) 430-3049
LICENSING EVALUATOR SIGNATURE:	DATE: 06/25/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/25/2021

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245

FACILITY NAME: BENABU FAMILY CHILD CAEW	FACILITY NUMBER: 197494814
	VISIT DATE: 06/25/2021

NARRATIVE

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Applicant has submitted a disaster plan and demonstrated control of property at the above address by Lease Agreement.
The following were discussed: No smoking, no infant walkers, Johnny jumpers, exersaucers or any other item that falls into that category.
The LPA also discussed earthquake safety and necessity of drills, required forms for children’s files, facility files and posting requirements. Fingerprint clearance, transfer process and capacity / ratios. Regulation 102416.3 was explained and discussed with applicant.
The following were discussed:
Novel Corona virus (COVID-19) Los Angeles County Department of Public Health Guidance for Early Childhood Education Providers.
Additional information available at: www.publichealth.lacounty.gov
Applicant was informed that it is required by law to post the following in the facility:
● Emergency Disaster Plan (LIC 610A) - This must be posted in your home next to the telephone and
The Earthquake Preparedness Checklist (LIC 9148), must be attached to the LIC610A and available
to the public.
● Notification of Parents' Rights Poster (PUB 394) - This poster must be placed in an area of the home
where all parents can see it
● Facility License, (LIC 203)-Your Family Child Care Home License must be posted in an area of the
home where it can be easily seen.
● Notice of Site Visit (LIC 9213) must remain posted for 30 days (during the hours that children are in care) after each site visit by a licensing representative.● Any licensing report documenting a type “A” citation must be posted for 30 days during the hours that children are in care.● Any licensing report or other document verifying compliance or non-compliance with the Department’s order to correct a Type “A” deficiency must be posted for 30 days during the hours that children are in care. Employee records must be maintained by the applicant and shall contain the following: LIC9052/Employee Rights, LIC 9108 Mandated Reporter Form, an employment contract or application containing the following information: Employees Full Name, Date of Birth, Driver's License Number, Date of Employment, Documentation of Health and Safety Training, Duties of the employee. Licensee is reminded that records for employees as well as children must be maintained for 3 years after separation for the FCCH.

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SUPERVISOR'S NAME: Mary Ruiz	TELEPHONE: (424) 301-3061
LICENSING EVALUATOR NAME: Margarit Sislyan	TELEPHONE: (424) 430-3049
LICENSING EVALUATOR SIGNATURE:	DATE: 06/25/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/25/2021

LIC809 (FAS) - (06/04)

Page: 3 of 3

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245

FACILITY NAME: BENABU FAMILY CHILD CAEW	FACILITY NUMBER: 197494814
	VISIT DATE: 06/25/2021

NARRATIVE

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LPA discussed the safe sleep for baby pamphlet. Each infant shall be constantly supervised
and under direct visual observation by an adult person at all times. Under no circumstances shall any infant be left unattended. In order to visually observed and supervise sleeping infants there should be no obstruction to the view of the infants, which could include transparency walls and/or half walls. LPA recommend that infants sleep safest in crib with no bumpers, pillows, blankets, or toys, and on their backs, and every sleep time counts to reduce the risk of SIDS and other sleep related causes of infant death.

Incidental Medical Services (IMS) policy was discussed. For IMS information see Evaluator Manual - Regulation Interpretations and Procedures for Child Care Centers Sections 101173 and 101226. When any IMS is provided, an updated Plan of Operation that includes IMS must be submitted to the Department. The following information regarding ADA was provided: US Department of Justice (USDOJ) toll-free ADA Information Line at (800) 514-0301 (voice)/ (800) 514-0383 (TTY) and link to publication: Commonly Asked Questions about Child Care Centers and the ADA, available at: http://www.ada.gov/childqanda.htm.

The following needed before licensure:
1. The licensee shall ensure the inaccessibility of in-ground pool on the premises of the main house located at 6306 Melvin Ave.,Tarzana CA 91335 by surrounding the pool with a fence.
Fences shall be at least five feet high and shall be constructed so that the fence does not obscure the pool from view. The bottom and sides of the fence shall comply with Division 1, Appendix Chapter 4 of the 1994 Uniform Building Code. In addition to meeting all of the aforementioned requirements for fences, gates shall swing away from the pool, self-close and have a self-latching device located no more than six inches from the top of the gate. Pool covers shall be strong enough to completely support the weight of an adult and shall be placed on the pool and locked while the pool is not in use.
2. The following shall be posted:
Emergency Disaster Plan (LIC 610A)
The Earthquake Preparedness Checklist (LIC 9148), must be attached to the LIC610A and available
to the public.
Notification of Parents' Rights Poster (PUB 394) - This poster must be placed in an area of the home
where all parents can see it

Exit interview

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SUPERVISOR'S NAME: Mary Ruiz	TELEPHONE: (424) 301-3061
LICENSING EVALUATOR NAME: Margarit Sislyan	TELEPHONE: (424) 430-3049
LICENSING EVALUATOR SIGNATURE:	DATE: 06/25/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/25/2021

LIC809 (FAS) - (06/04)

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